Monday, September 25, 2023
| Time After Treatment Completion (% of Total Recurrences) | |||||||
| Patients (n) | Total Relapses | 6 mo | 12 mo | 18 mo | 24 mo | 36 mo | 48 mo |
| HL (160) | 40 | 14 (35%) | 14 (35%) | 5 (12.5%) | 3 (7.5%) | 3 (7.5%) | 1 (2.5%) |
| Indolent NHL (78) | 30 | 8 (27%) | 8 (27%) | 5 (17%) | 4 (13%) | 3 (10%) | 2 (7%) |
| Aggressive NHL (183) | 48 | 19 (40%) | 8 (17%) | 16 (33%) | 3 (6%) | 1 (2%) | 1 (2%) |
Incidence of Lymphoma Relapses Detected With Routine Surveillance FDG-PET
Abbreviations: HL, Hodgkin lymphoma; NHL, non-Hodgkin’s lymphoma.
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Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine
This activity is intended for primary care physicians, oncologists, and other physicians who care for patients with lymphoma.
The goal of this activity is to analyze the use of imaging studies for the surveillance of patients with lymphoma.
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Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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Patients with lymphoma commonly undergo routine imaging studies after treatment completion, yet the appropriate interval, duration, and modality of follow-up, and the overall efficacy of various approaches is unclear. Existing guidelines are vague and not evidence-based, and consequently, practice patterns are varied. Most surveillance approaches in lymphoma have focused on early detection of recurrence, with the hope of prolonged survival and potential cure. Concerns regarding the prognostic value of frequent scanning, cost-effectiveness, and long-term risks associated with prolonged radiation exposure have led many to question the role of routine imaging in this setting. Given the multiple lymphoma subtypes and the clinical heterogeneity of these entities, a single approach to follow-up may not be reasonable. Much of the available literature focuses on Hodgkin lymphoma, and may not be generalizable. Retrospective series show that most relapses are detected by signs and symptoms regardless of the imaging schedule. In summary, clinicians are still left with “expert opinion” to guide them. This article examines the available data outlining the role of surveillance imaging in lymphoma. (JNCCN 2011;9:575–585)
Large randomized trials of surveillance methods guide follow-up testing in patients with breast cancer. These studies showed no survival benefit and no impact on health-related quality of life with routine intensive reimaging studies.[1,2] Data such as these do not exist for most other cancers, including lymphoma. Consequently, guidelines for lymphoma follow-up are based on limited retrospective analyses and opinion.
The widespread use of CT scans to assess response to lymphoma treatment, along with the recognition that a subset of patients with relapsed lymphoma can be cured with autologous stem cell transplant, led to the adoption of CT for monitoring patients for early relapse. The frequency with which CT was used in the posttreatment setting largely mimicked the interval adopted for routine follow-up visits. A panel of Hodgkin lymphoma experts at the Cotswolds Meeting in 1989 recommended follow-up every 3 months for the first 2 years, followed by 4-month intervals during year 3; 6-month intervals during years 4 and 5; then annually thereafter.[3] The panel further advised that “the frequency and type of radiological studies should reflect the initial sites of disease.”
[18F]-fluorodeoxyglucose- (FDG) PET/CT has largely supplanted CT for assessing response at the end of treatment for both Hodgkin lymphoma and diffuse large B-cell lymphoma (DLBCL). Despite the usefulness of FDG-PET for initial staging and evaluations at treatment completion, its role as a surveillance modality has not been borne out in small retrospective studies.[4–8] FDG-PET often can differentiate viable tumor from posttreatment fibrosis or necrosis, adding valuable information to that obtained with CT for response assessment.[9] Two meta-analyses support the important prognostic value of FDG-PET performed at the completion of therapy for lymphoma.[10,11] The most recent lymphoma response criteria incorporate FDG-PET into the definition of response,[12] using criteria established by the International Harmonization Project in Lymphoma (IHP) to interpret end-of-therapy FDG-PET as positive or negative.[13]
Practice patterns are often driven by habit and reflect a disregard of the available data, with many survivors undergoing routine scans years beyond the expected likelihood of detecting recurrence, whereas others have a limited period of routine imaging despite a constant risk of relapse. The incidence and duration of risk of relapse varies significantly according to lymphoma subtype (Figure 1). In DLBCL, the 2-year progression-free survival (PFS) rate is 65% to 70% with more than 80% of relapses occurring within the first 3 years and only 10% after 5 years.[14,15] In contrast, the 2-year PFS rate for follicular lymphoma is approximately 80%, with a relatively constant rate of relapse at 8% to 10% per year, which extends at least 5 to 8 years.[16,17] Early-stage Hodgkin lymphoma is associated with a 5-year PFS rate of 86% to 92% depending on risk factors with few patients relapsing beyond 5 years.[18,19] In advanced-stage Hodgkin lymphoma, 2- and 5-year failure-free survival (FFS) rates are approximately 70% and 65%, respectively, with 80% to 90% of relapses occurring in the first 2 years.[20] Nodular lymphocyte-predominant Hodgkin lymphoma is associated with a continuous rate of relapse even beyond 10 years, with 5- and 10-year PFS rates of 74% and 60%, respectively.[21] Based on the patterns of relapse, surveillance imaging in DLBCL and Hodgkin lymphoma is unlikely to be beneficial beyond the first 2 years. In contrast, an intensive monitoring approach for early relapses in indolent lymphomas will only capture a fraction of the total number of relapses.
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EnlargeRelapse Patterns in Lymphoma. Abbreviations: DLBCL, diffuse large B-cell lymphoma; FL, follicular lymphoma; HL, Hodgkin lymphoma.
Retrospective studies show that few relapses are detected with routine scanning and that suspected relapses are frequently not confirmed, resulting in additional unnecessary procedures. Despite the low yield and the low positive predictive value (PPV) associated with routine imaging in lymphoma, many of the current guidelines continue to recommend an intensive surveillance approach. This review summarizes existing guidelines and published data evaluating surveillance scans for lymphoma.
